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PERMITTEE NAME'ADDRESS <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (DMR) <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />YEAR MO DAY YEAR MO DAY <br />FROM - TO <br />:rm Approvetl <br />~~R Nn. 204(l-0(K14 <br />NOTE: Read Instructions before completing this form. <br />_ - --r-- <br /> <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION <br />~ tFituutn~r SAMPLE <br />OF TYPE <br />ANALYSIS <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br />MEASUREMENT . <br /> - - ` ,r <br />? `~I t` <br /> PERMIT <br />REQUIREMENT ~~•:: - :r ~ ;r~ • _< .~ - <br />,. .r , ., lei <br />-~ - '~ - ~::I <br />P~~T <br />- -.: X - <br /> SAMPLE <br />MEASUREMENT t ~~ ~ , <br /> < • k ~j <br />'ice - <br /> PERMIT <br />REQUIREMENT 31-'3t•r -r st ~ RF=P :7R T <br />! 11:~T I'1A:~. ; #~f iF'i>•~t'R' # 9t •7F 3E 3f •r .~ if <br />A ~r ,i <br />:, n .. _ <br />C <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT <br /> <br /> PERMIT <br />REQUIREMENT <br /> SAMPLE <br />MEASUREMENT - <br /> <br /> PERMIT <br />REQUIREMENT <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER ~ :cmh under ~enul _ ~' iau ti±at this J,tiumrnt :uW a{l atW.hincnts icerc <br />prcpw~rd w:dcr my d!;can,n or sup:n-t5u?n n~i aucaduncr Huh a s:,tcm de.ignca <br />to aaur that yualifit=t Ixrwunal pn,~rh gadur :utd r~::uu:+tc :hr mfnrmatinn <br />. - - r '.: , n r- _' suhmuted R:tieJ nn m~ mgwn .d ih. pet.nn nr I,cnnn, ah~~ u>.innec Ihr system. <br /> <br />-nmation <br />the inf <br />the i <br />f <br />tion <br />hl <br />h <br />o <br />~ <br />~ ; 'v--' TELEPHONE <br /> <br /> <br /> <br />.. <br />.- <br />- ~- <br /> <br /> <br /> <br />1 is DATE <br /> <br /> <br /> <br />. <br /> <br /> <br />- <br />. <br />. <br />cnn~ <br />n <br />„men <br />c f <br />r gm <br />ur tlr,. u p ts. m. dtn tls r~ ~;*ma <br />I .ul+miuc[i n, t„ the l.~,t .•i my kno~~kd~r and brLcf, tTUr. -ic, ur<re..md compfetc SIGNATURE OF PRINCIPAL EXECUTIVE <br />I .un agar that thCrr erc -ignYtiomt pcnaltles for ,ubmunng lal:c mL,rntnu°n' <br />Tvnen n0 OL71WTFr1 ino!udnn• th. nrnsrMiv~ ~d fine snd mtnnsnnmau L,r kro,e me ~t.dunon_r OFFICER OR AUTHORIZED AGENT AREA NUMBER <br />CODE YEAR MO DAY <br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS (Reference atl attachments here) <br />Form 332(1-t (Rev. 3i99) Previous editions may be uses. <br />- - _ .~ <br />;t This i; a-3-part nlrnl. <br />